1. Clinical Management of Dengue in
the Primary Care Setting
Andre Sookdar

2. Objectives
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Course of Dengue Illness
Approach to Suspected Dengue Patient
Recognizing Severe Dengue
Clinical Management
Good vs Bad Practice

3. Course of Dengue Fever
• After incubation, Dengue Fever begins abruptly.
• Three Phases; Febrile, Critical and Recovery.
• Severe Dengue may occur from Day 4-5 instead of
the recovery phase. This may involve
Hypovolemic/Hypotensive shock, Coagulation
abnormalities or Severe Organ impairment.
• Most cases recover without hospital management.
• Triage, Guidelines and management decisions at the
primary care level can help in identifying those at risk
of severe Dengue and needing hospital care.

4. Course of Dengue Fever

5. At the Primary Care Level
• Recognize the Febrile patient could have Dengue.
• Notify the Public Health Authorities early about suspected
cases.
• Managing the early Febrile Phase of Dengue.
• Recognize the Critical Phase as plasma leakage and to
initiate fluid therapy.
• Recognize the Warning Signs and the need for referral.
• Recognize and manage severe plasma leakage and shock,
severe bleeding and organ impairment promptly and
adequately.

6. Approach to Suspected Dengue Patient
• Stepwise approach
• Step 1 – Overall Assessment
1. History
2. Physical Examination
3. Investigations
• Step 2 – Diagnosis, assessment of disease phase
and severity
• Step 3 – Management
1. Group A, B or C

7. History
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Date of onset of fever/illness
Quantity of oral intake
Assessment of Warning Signs
Diarrhoea
Change in mental state/seizures/dizziness
Urine output
Other – neighbourhood dengue, travel to endemic
areas, co-existing conditions, risk factors for
Leptospirosis, Malaria, HIV

9. Examination
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Mental State
Hydration Status
Hemodynamic Status
Tachypnea/Acidotic Breathing/Pleural Effusion
Abdominal Tenderness/Hepatomegaly/Ascites
Rash and Bleeding manifestations
Tourniquet Test
Temperature

10. • “ isles of white in the sea of red”
• Hemorrhagic Rash

11. Tourniquet Test
• Blood Pressure Cuff is applied and inflated midway
between the systolic and diastolic pressures
• Leave on for five minutes
• Positive if there are more than 10 petechiae in one
inch circle.
• Dengue Hemorrhagic Fever usually results in 20 or
more petechiae.
• Confounding factors include
premenstrual/postmenstrual women and sundamaged skin

12. Positive
Negative

13. Investigations
• CBC – baseline HCT, low WBC, low Platelet
• Rising serial HCT – plasma leakage/critical phase
• Confirmatory tests (not necessary in acute
management)
• LFT’s, Glucose, Electrolytes, Urea, Creatinine,
Bicarbonate, Cardiac Enzymes, ECG, Urinalysis

14. Management
• Disease Notification – suspected and confirmed
cases in Dengue endemic countries. Confirmation can
come later for suspected cases. Early notification is
key to initiate vector eradication.
• Clinical manifestations and circumstances leads to
patient being sent home (Group A), referred for inhospital management (Group B) or emergency
treatment and urgent referral (Group C.)
• Education of patient and relatives on disease and
vector management

15. Group A
• No Warning Signs
• No significant co-morbid conditions or social
circumstances
• Must be able to tolerate adequate oral fluids
• Must be passing urine at least every six hours
• May be sent home with instructions and plans for
follow-up
• Bed rest; fluid intake; paracetamol
• Daily review for disease progression

16. Group B
• Stable patients with Warning Signs or patients without the
warning signs but have significant co-morbid conditions
or social circumstances.
• Referral for in-hospital care
• Obtain baseline CBC with HCT
• Encourage oral fluids; if not tolerating for 0.9% N/S or
Ringer’s Lactate at maintenance rate.
• For those with Warning signs give 0.9% N/S or Ringer’s
Lactate at 5-7ml/kg/hr for 1-2 hrs, then reduce to 35ml/kg/hr for 2-4 hrs, then reduce to 2-3 ml/kg/hr
according to clinical response.

17. Group B
• Reassess, repeat HCT
• If HCT is stable then continue at 2-3ml/kg/hr.
• If worsening of vital signs or rising HCT increase to 510 ml/kg/hr for 1-2 hrs then reassess
• Observe urine output and fluid intake

18. Group C
• Warning signs present plus features of:
Severe plasma leakage and shock
Fluid accumulation with respiratory distress
Severe bleeding
Severe Organ impairment
• For Emergency Treatment and Referral
• CBC and baseline HCT
• Other organ function tests
• Start IV fluid resuscitation with crystalloid solutions at 510 ml/kg/hr for 1 hr.
• Reassess patient

19. Group C
• If patient improves gradually reduce to 5-7 ml/kg/hr for
1-2 hrs, then 3-5 ml/kg/hr for 2-4 hrs then 2-3 ml/kg/hr
for 2-4 hrs
• If patient is still unstable check HCT
If HCT increases or is still high repeat a second bolus
at 10-20 ml/kg/hr for one hr. If there is improvement
reduce to 7-10 lm/kg/hr for 1-2 hrs and continue to
reduce as the above
• If HCT decreases this indicates bleeding and need for
transfusion

25. Conclusion
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Course of Dengue Illness
Primary Approach to Suspected Dengue Patient
Recognizing Severe Dengue
Clinical Management of Groups A, B, C
Good vs Bad Practice

26. Thank You